Day One: Telluride East Reflections

By Linda Hunter, RN, PhD Student

I continue to learn from and be impressed with my health professional peers and feel like we are starting to get closer to the top of the patient safety mountain and picking up speed as we move “up and over”. I am thrilled to see the interaction and reflection amongst the multi-disciplinary group we have.
When Rose mentioned that Lewis was with us and watching – it reminded me of when my sister passed away due to a medical error involving morphine. She was 24 yo and legally blind due to juvenile diabetes but was vibrant, intelligent and fun! She died while I was working in Saudi Arabia and when I was coming home on the plane (crying the whole way) I looked out and saw her walking on the clouds and smiling at me. We can never forget the loved ones we have lost due to error – every “error” has a face and all have a story that continues. Let’s continue to work together and realize how vital it is that we all have and use this knowledge and then share and spread the patient safety knowledge with our peers back home.

By Lynne Karanfil RN

What makes a train? Not just the engine or cars but the coupling device that hooks it together….Professor Cliff Hughes indicated….we need to be a team to make change happen…brilliant!

And then Garrett, 2nd year medical student asked me why don’t all medical school curricula have a course on patient safety like Telluride East? Spot on Garrett! All healthcare providers should have this basic training! Day one at Telluride East was phenomenal! I always learn something new from listening to Lewis’s story and how to engage the healthcare community to become better change agents. Day two..bring it on!

By Rose Ngishu

From tears to transparency is a very powerful story that captures many of the barriers to patient safety in our hospitals. It is more than an irony of ironies. As Helen Haskell pointed out, it is sad that “if Louis had been anywhere other than the hospital, he would still be alive.” Until every patient is safe all the time in the hospital, we are challenged to keep speaking up. And when that goal is achieved, we have yet to keep speaking up on matters of safety.

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2 Responses to Day One: Telluride East Reflections

  1. Linda Hunter RN PhD student says:

    I continue to learn from and be impressed with my health professional peers and feel like we are starting to get closer to the top of the patient safety mountain and picking up speed as we move “up and over”. I am thrilled to see the interaction and reflection amongst the multi-disciplinary group we have.
    When Rose mentioned that Lewis was with us and watching – it reminded me of when my sister passed away due to a medical error involving morphine. She was 24 yo and legally blind due to juvenile diabetes but was vibrant, intelligent and fun! She died while I was working in Saudi Arabia and when I was coming home on the plane (crying the whole way) I looked out and saw her walking on the clouds and smiling at me. We can never forget the loved ones we have lost due to error – every “error” has a face and all have a story that continues. Let’s continue to work together and realize how vital it is that we all have and use this knowledge and then share and spread the patient safety knowledge with our peers back home.

  2. Linda Hunter RN PhD student says:

    Day 2 Reflections….
    I am super impressed with:
    – the open, respectful, and friendly demeanour of Seth as I walked around the hospital with him this morning. He was an excellent choice for working at MedStar Health.
    – the phenomenal presentation by Terry on human factors engineering this afternoon. Terry is an expert in his field who allows his listeners to feel at ease to learn and to ask questions in an atmosphere of comfort. This is the best presentation I have seen on this topic.
    I have been giving thought to nurse-physician communication and it would appear to me that we sometimes fail to mention the ‘fear’ that medical students and residents sometimes have in approaching senior nurses. We have spoken a lot about nurses lacking assertive behaviour in speaking up with their physician peers but we must not forget that residents change clinical rotations frequently hence can feel awkward in approaching other professional staff on the units that possess so much knowledge gained from working on the floor for a long time. I still remember the incident when a cardiac surgery ICU resident working with me on a patient going “sour” was asked to set up the cardiac monitor for a cardiac output and looked at me and stated “Linda, we are not trained on the equipment!”. So how do we each help our multi-disciplinary peers to gain assertion and confidence in communication no matter what professional group they belong to? I think by remembering that we are all human, and all feeling new and lost at some time – so would all benefit from a smile, recognition and a friendly helping hand. It costs nothing and creates a strong professional bond!

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